Low performance of bleeding risk models in the very elderly with atrial fibrillation using vitamin K antagonists.

UNLABELLED: Essentials Under-treatment of oral anticoagulation in the elderly with atrial fibrillation is common. As bleeding prediction is challenging, we compared HAS-BLED, ATRIA and HEMORR2 HAGES. All three were associated with major bleeding in the elderly, but with poor predictive abilities. Future studies with focus on elderly-specific risk factors for bleeding are warranted. SUMMARY: Background Anticipated bleeding complications contribute to underuse of oral anticoagulants, especially in elderly patients with atrial fibrillation (AF). Bleeding risk models could provide guidance; however, these were developed in the general AF population. Objective To study and compare the performance of the HAS-BLED, ATRIA and HEMORR2 HAGES for major bleeding in very elderly AF patients. Methods Subjects were a random sample (N = 1157) of AF patients ≥ 80 years using a vitamin-K antagonist with prospective clinical follow-up from 2011 to 2014. The primary outcome was major bleeding (International Society on Thrombosis and Haemostasis criteria). Results Patients aged 84 years (median; 25th-75th 82-87) were classified as low risk by HAS-BLED (25.2%), ATRIA (59.6%) and HEMORR2 HAGES (23.3%). Three-year rates of major, clinically relevant and any bleeding were 6.7%, 28.3% and 42.3%, respectively. We observed a statistically significant association for all models with major bleeding, but discriminatory abilities were rather poor (C-statistics < 0.60) without clear superiority for any of the three. Only two (anemia and antiplatelet therapy) of the various classical risk factors were associated with bleeding. An estimated risk-benefit profile indicated a favorable trade-off for oral anticoagulation in this specific cohort (number needed to treat, 22; number needed to harm, 91). Conclusions In this large prospective cohort of very elderly AF patients, the currently used bleeding risk scores were all associated with major bleeding, but with poor predictive abilities. Use of the ATRIA model may inadvertently result in less attention being paid to modifiable risk factors in this particular population. In light of the issues of under-treatment and the suggested favorable risk-benefit profile, future models with incorporation of elderly-specific risk factors may provide more guidance in this growing population of AF patients.

[Reperfusion therapy for patients with an acute myocardial infarct with ST-segment elevation: fibrinolysis versus transport to a cardiac center for primary angioplasty]. / Reperfusietherapie bij patiënten met een acuut myocardinfarct met ST-segmentelevatie: fibrinolyse versus transport naar een hartcentrum voor primaire angioplastiek.

Although fibrinolytic therapy for acute myocardial infarction is widely used and can be administered prior to hospitalisation, it is only successful in restoring full early coronary patency in about 60% of patients and has a 0.5% to 1% risk of severe side effects. Primary percutaneous coronary angioplasty carried out as an alternative to fibrinolysis avoids the risk of fibrinolytic therapy and restores patency in nearly 90% of cases. Data from randomised trials of primary angioplasty versus fibrinolytic therapy in acute myocardial infarction reveal that angioplasty results in a significant reduction in mortality. Furthermore, primary angioplasty can be improved by means of a new pre-angioplasty drug therapy (so-called facilitated primary angioplasty). Transport to a cardiac centre for primary angioplasty (of which there are 14 in the Netherlands) is feasible and safe. Although the time to treatment is delayed by a further 90 minutes, it tends to save lives and prevent strokes and it also significantly reduces the incidence of reinfarction. Interestingly, the time gained to treatment with prehospital fibrinolytic therapy compared to in-hospital therapy gave an outcome similar to that found upon comparing transport and primary angioplasty. Rescue procedures (angioplasty) within 24 hours are necessary in about 30% of patients who are initially treated with lytic therapy. These results support prehospital triage for fibrinolysis or transport to a cardiac centre, where early angioplasty can be performed if clinically indicated. A trial to determine the policy of choice is at present being conducted in the Netherlands.

Abortion of acute ST segment elevation myocardial infarction after reperfusion: incidence, patients' characteristics, and prognosis.

OBJECTIVES: To study the incidence and patient characteristics of aborted myocardial infarction in both prehospital and in-hospital thrombolysis. DESIGN: Retrospective, controlled, observational study. SETTING: Two cities in the Netherlands, one with prehospital thrombolysis, one with in-hospital treatment. PATIENTS: 475 patients with suspected acute ST elevation myocardial infarction treated before admission to hospital, 269 patients treated in hospital. MAIN OUTCOME MEASURES: Aborted myocardial infarction, defined as the combination of subsiding of cumulative ST segment elevation and depression to < 50% of the level at presentation, together with a rise of creatine kinase of less than twice the upper normal concentration. A stepwise regression analysis was used to test independent predictors for aborted myocardial infarction. RESULTS: After correction for "unjustified" thrombolysis, 17.1% of the 468 prehospital treated patients and 4.5% of the 264 in-hospital treated patients fulfilled the criteria for aborted myocardial infarction. There was no difference in age, sex, risk factors, haemodynamic status, and infarct location of aborted myocardial infarction compared with established myocardial infarction. Time to treatment was shorter in the patients with aborted myocardial infarction (86 versus 123 minutes, p = 0.05). A shorter time to treatment, lower ST elevation at presentation, and higher incidence of preinfarction angina were independent predictors for aborted myocardial infarction. Aborted myocardial infarction had a 12 month mortality of 2.2%, significantly less than the 11.6% of established myocardial infarction. CONCLUSION: Prehospital thrombolysis is associated with a fourfold increase of aborted myocardial infarction compared with in-hospital treatment. A shorter time to treatment, a lower ST elevation, and a higher incidence of preinfarction angina were predictors of aborted myocardial infarction.

Between the devil and the deep blue sea: an unusual kind of late cardiac tamponade with a therapeutic dilemma.

A 67-year-old patient underwent a left pneumectomy because of a moderately differentiated squamous cell carcinoma. Two weeks later, while still in hospital, he suddenly experienced an acute increase in dyspnoea. Pulmonary embolism was considered. However, echocardiography showed compression of the right ventricle and right atrium by an intrapericardial mass, confirmed by computed tomography. Following signs of a large thrombus in the inferior vena cava, pericardiocentesis was considered undesirable due to possible dislocation resulting from the sudden changes in intrapericardial pressure. Re-thoracotomy was equally undesirable because of the recent operation and status of the patient. After stabilisation and extensive consulting the patient was referred for pericardiocentesis by sternotomy. Huge blood clots were removed from the pericardial space. No thrombus mass was found in the inferior vena cava. The patient recovered uneventfully.

Time from symptom onset to treatment and outcome in prehospital thrombolysis for acute ST-elevation myocardial infarction.

BACKGROUND: Prehospital thrombolysis for acute ST-elevation myocardial infarction shortened treatment by 60 minutes, and created a large patient group who were treated within two hours. OBJECTIVES: We analysed our database of patients undergoing prehospital treatment for acute ST-elevation myocardial infarction in search of characteristics for a better outcome in the early treatment group. METHODS: From 1994 to 2000 a total of 475 patients were treated using prehospital administration of anistreplase (in 407 patients) or reteplase (in 68 patients) after diagnosis was confirmed with transtelephonic transmission of the ECG. There was no age limit. The patient data were divided into two groups: one treated within two hours after onset of pain (291 patients, 62%), and one treated later (171 patients, 37%). Thirty-day mortality, symptoms and clinical signs of heart failure were used as parameters of outcome. Both univariate and stepwise logistic regression analyses were used to test 30-day mortality against age, actual time to treatment, prior myocardial infarction, hypertension, diabetes, anterior myocardial infarction, Killip class, systolic blood pressure and heart rate at presentation. RESULTS: Overall 30-day mortality was 9.1%. Overall heart failure was in 16.6% of patients. Both mortality (5.5% vs. 15.5%, p<0.02) and heart failure (12.7% vs. 23.2%, p<0.02) were significantly lower in the early treatment group compared with the group treated late. Independent parameters showing a relation with 30-day mortality were age, time to treatment, hypertension and prior myocardial infarction. Age, time to treatment, hypertension and hyperlipidaemia were identified as predicting heart failure within the first 30 days. CONCLUSION: With prehospital thrombolysis, both 30-day mortality and heart failure were lower in an early treatment group with acute ST-elevation myocardial infarction. Independent variables for 30-day mortality were age, hypertension, prior myocardial infarction and time to treatment, and age, hypertension, hyperlipidaemia and time to treatment were independent predictors for heart failure.

[Atrial fibrillations: daily occurrence possibly leading to embolism in an extremity]. / Boezemfibrilleren: alledaags, maar mogelijk leidend tot embolisatie naar een extremiteit.

A 64-year old woman had been tired and short of breath for the previous few months. During the past few days she had experienced disruptions in the movement and feeling of the right arm and both feet as well as a loss of strength and a heavy feeling in her right leg. Due to atrial fibrillation she had recently started using digoxin and due to possible arterial embolisms in the extremities she had recently started using acenocoumarol. Further investigations revealed one large thrombus in the left atrium, two large thrombi in the left auricle and a serious constriction in the right iliac artery. The thrombi were treated with heparin and oral anticoagulants; the ischaemia which probably occurred as a result of this was successfully treated with embolectomy. After the cardiac thrombi had disappeared, the patient was electrically converted to sinus rhythm. One month later, the patient was still in sinus rhythm and her clinical picture had improved. As she does not feel the atrial fibrillation, she will be permanently maintained on oral anticoagulants. In patients with atrial fibrillations, the possibility of an embolisation towards the extremities deserves serious consideration.

Friction and fluid: correlating pericardial effusion and pericardial friction rub.

BACKGROUND: In this study the relationship between pericardial friction rub (PFR) and the degree of pericardial effusion was investigated. METHODS: A retrospective study was performed involving all patients for whom the diagnosis pericarditis was made on clinical grounds (type of chest pain, fever, laboratory findings and/or electrocardiographic signs) in the period 1990-1999. In this patient group (n=138) the presence of PFR was correlated against the amount of pericardial effusion measured echocardiographically. RESULTS: No statistically significant correlation between the presence of PFR and the amount of pericardial effusion was observed. It is, therefore, a misconception that the presence of a PFR signifies absence or only a small volume of pericardial effusion. Our results are in line with the literature. CONCLUSION: Based on this study and results presented in the literature, we postulate that the friction rub associated with pericarditis is not caused by friction of the 'roughened' pericardial layers, as is commonly propagated. Instead fibrin strands caused by the inflammation, connecting the two pericardial layers, may function as snares and generate, through the movements of the heart, the typical triphasic pericardial friction rub.

[Benefit of prehospital thrombolysis in the treatment of acute myocardial infarction]. / Winst van prehospitale trombolyse bij de behandeling van het acute myocardinfarct.

Randomized studies comparing early and late thrombolysis in the treatment of acute myocardial infarction show that mortality is lower if therapy is administered at an early stage, and especially if it is administered during the first hour of symptoms. Since only few patients can actually be treated within one or two hours, a search was made for time gaining strategies, including prehospital thrombolysis. In the region of Nijmegen, the Netherlands, it proved possible with prehospital treatment to treat 25% of the patients in the first hour after onset of ischaemic symptoms. The group given prehospital treatment included almost three times as many aborted infarctions as the group treated in hospital. In clinical practice, the proportion of aborted infarctions and more pronounced ECG abnormalities, namely, increase the probability of early prehospital treatment as well as the risk of death. Conditions of the organization of prehospital thrombolysis in a region are equipment for ECG transmission by telephone, good co-operation between cardiologists and cardiologic care units and special training of paramedics and general practitioners.

Effect of prehospital thrombolysis on aborting acute myocardial infarction.

On administering thrombolysis in a prehospital setting, we found a threefold increase in the incidence of abortion of myocardial infarction, compared with the in-hospital program of a nearby hospital. Assessment of aborted myocardial infarction may be a better criterion for the efficacy of early thrombolysis than mortality data.

Atrial natriuretic peptide after myocardial infarction.

Plasma concentrations of atrial natriuretic peptide (ANP) after acute myocardial infarction were measured at fixed times during 48 hours in 38 patients admitted to the hospital within 4.4 hours after the onset of symptoms. Three hours after admission, the mean concentration of ANP was significantly lower than that at the time of admission. Thereafter it rose steadily until 15 hours after admission. ANP concentrations measured in each patient at the time of admission and the individual mean ANP concentrations during the first 48 hours after admission correlated weakly but significantly with the size of the infarct and the left ventricular function. Neither the site of the infarct, the occurrence of reperfusion, nor the number of coronary vessels affected influenced the ANP concentration. In 24 patients in whom cardiac catheterization was performed, no relationship between ANP concentrations and left ventricular pressures was observed. Determination of ANP concentrations seems to be of little value in assessing cardiac function after acute myocardial infarction.